We Need a Pap Smear for Breast Cancer

Photograph of Pink Ribbon

Mammography screening just doesn’t work very well in women before menopause, as the U.S. Preventive Services Task Force has now recognized. Everyone hoped that it would. But in 1993, it became clear from well-done studies that our hopes hadn’t panned out, and screening just didn’t work well for women in their 40s (or at all, for even younger women). The fact that most women didn’t know this, and instead received a falsely optimistic message about the life-saving benefits of once-a-year mammography screening, was incredibly frustrating. More background here.

At the National Women’s Health Network, we’re glad that the federally appointed task force has told the truth about what studies have found. Now women have a better chance of getting an honest assessment about the value of a heavily promoted technology. Information is always a good thing.

But I’m not at all happy today. Not even to be proven right about things that I took a lot of criticism for saying. Rather, I’m outraged. We’ve known for 16 years that mammography screening doesn’t work well for women before menopause, and not at all for women under 40. And at the same time, we’ve known that a significant number of breast-cancer cases occur in women under 50. So once we knew mammography wasn’t good enough, the next step was obvious—we needed to find something better.

Women need the equivalent of a pap smear for breast cancer screening. Pap smears are far from perfect, but the technology works equally well in 18-year-olds and 68-year-olds. How far have we gotten on a pap smear equivalent for breast cancer? Not very far at all. And that’s why I’m outraged. A huge amount of money has been spent on breast-cancer research in the last 16 years, but far too little has gone for research into truly new forms of screening. Who suffers as a result? All young women, of course, but African-American women suffer more than everyone else. For some reason that’s not yet fully clear, African-American women are more likely to develop breast cancer before age 40 than are white women. So if we fail to develop a screening that works at all ages, it’s African-American women who get hurt most. Let’s get moving.

Another version of this post appears here.

Photograph of pink ribbon by Photodisc/Getty Creative Images.

Tags: breast cancer, mammograms, mammography, national women's health network, pap smear, u.s. preventive

Cindy Pearson is the executive director of the National Women's Health Network.

Comments

Understanding HALO

By: HALO | Tue, 11/24/2009 - 17:51

First disclosure: I am the Director of Marketing for the HALO Breast Pap Test and I want to try to clear up the most common confusion about HALO.

HALO's purpose is to find precancerous changes that indicate a woman is at high risk for developing breast cancer in the future. You are correct that NAF cytology is a marginal diagnostic for detecting existing cancer, but that is not the purpose of HALO. The science supporting NAF cytology for breast cancer risk assessment is solid and I will summarize it at the end of this.

Why do we wait until a woman has breast cancer before taking any action? We don't do that with heart attacks; we test blood pressure and cholesterol and intervene to prevent the attack. The reason is that it's much harder to identify individual women at high risk for breast cancer. 70% of women who get breast cancer have no identifiable risk factors, and 8 out of 9 women diagnosed with breast cancer have no direct relatives with the disease. We think we're safe if we don't have family history, but that's just wrong.

With the cervical Pap test, cells are scraped from the cervix and examined under a microscope. When precancerous changes are found, the doctor intervenes to prevent the cancer from developing. The cervical Pap is largely credited for reducing cervical cancer deaths from over 50,000 women annually to about 3,500.

Another important point is we have no tools to screen younger women for breast cancer other than physical breast exams, but by the time a lump can be felt, the cancer has been growing about 10 years. Why wait when HALO works in women 25 and older? Mammograms aren't effective in women under 50 with dense breast tissue, which obscures abnormalities, but HALO isn't impacted by breast density.

Katie27again, please review the clinical summary.

HALO Clinical Support Summary
Wrensch and Petrakis published their seminal work in 1992 and found that women with atypia in nipple aspirate fluid (NAF) were 4.9x relative risk (RR) of developing breast cancer compared to women who did not produce NAF. They manually collected NAF from 2,700 women who were then followed for an average of 12.7 years. They found that age makes a difference and the greatest relative risk was in women 25 to 54.1

Three other studies found similar RRs for women with atypia discovered through biopsy or Fine Needle Aspiration (FNA):

• DuPont & Page (JCNI 1985) found 5.3x RR with biopsy-proven atypia in 3,303 women followed for an average of 17 years.2
• Fabian (JCNI 2000) found 5x RR with atypia discovered by FNA in 480 women followed for 4 years.3
• Hartmann (NEJM 2005) found 4.2x RR with biopsy-proven atypia in 9,087 women followed an average of 15 years. Women under 45 had a 6.99x RR.4

Two other recent studies looked at risk associated with the presence of epithelial cells in NAF regardless of whether the cells were normal or atypical.
• Buehring (Epidemiology 2006) found 1.92x RR in 972 women followed for 25 years.5
• Baltzell (Biomed Central 2008) found a 1.9x RR in 946 women followed for 20.7 years.6

Our HALO clinical study (Proctor BMC Women’s Health 2005) proved that results from NAF collected via HALO are stratified equivalently to NAF collected manually (i.e. we have the same percentage of non-yielders, acellular samples, atypia, etc.).7

As you’ve noted, NAF cytology has been proven ineffective as a diagnostic for the presence of cancer (Kahn JCNI 2004)8 so it’s important that HALO’s use be restricted to risk assessment and not pathologic diagnosis. This is one of two reasons for the failure of ductal lavage. Because it was impractical for the primary care setting, its use was restricted to women already known to be high risk; therefore the results proved rather meaningless.

References:
1 Wrensch MR, Petrakis NL, et al. Breast cancer incidence in women with abnormal cytology in nipple aspirates of breast fluid. Am J Epidemiol 1992;135(2):130-41.
2 Dupont WD, Page DL. Risk factors for breast cancer in women with proliferative breast disease. NEJM 1985;312(3):146-151
3 Fabian CJ, Kimler BF. Short-term breast cancer prediction by random periareolar fine-needle aspiration cytology and the Gail Risk Model. JNCI 2000; 92(15):1217-1227
4 Hartmann LC, Sellers TA, Frost MA, et al. Benign Breast Disease and the Risk of Breast Cancer. NEJM 2005;353(3):229-237
5 Buehring GC, et al. Presence of epithelial cells in nipple aspirate fluid is associated with subsequent breast cancer: a 25-year prospective study. Breast CA Res & Treat 2006; 98:63-70
6 Baltzell KA, et al. Epithelial cells in nipple aspirate fluid and subsequent breast cancer
risk: A historic prospective study. BMC Cancer 2008, 8:75 doi:10.1186/1471-2407-8-75
7 Proctor KAS, Rowe LR, Bentz JS. Cytologic features of nipple aspirate fluid using an automated non-invasive collection device: a prospective observational study. BMC Women’s Health 2005;5:10.
8 Kahn SA, et al. Ductal Lavage Findings in Women With Known Breast Cancer Undergoing Mastectomy. JNCI 2004;96(20):1510-1517

OMG

By: Katie27again | Wed, 11/18/2009 - 11:46

HALO breast pap? Seriously? A soap-opera-star-driven infomercial for a "neomatrix" product? Nipple aspirate evaluation is NOT ANYTHING like a "breast pap." Sure it's FDA-approved for "screening," but that is oweing almost entirely to the consumerization of medicine. It isn't covered by insurance companies for a very good reason: To date, current research on this method of early BRCA detection indicates it has potential to be used as an adjunct screening tool alongside mammogram in high-risk patients. It is not effective for early breast cancer screeing in the genreal population. Maybe your obgyn is getting some money from neomatrix? Look, I think this proves the whole point: alternative screening methods are being researched--but a pap for the breast doesn't exist yet for sound scientific reasons.

There already is one!

By: jmurphy42 | Wed, 11/18/2009 - 10:33

My OB has been offering a "pap test for the breast" for several years now. It's called HALO, and here's the link I snagged off of my OB's website: http://www.paptestforthebreast.com/

Seriously, DoubleX

By: Katie27again | Wed, 11/18/2009 - 09:16

I hope your return to slate will streamline the content to keep ridiculous filler like this out. Come on, Cindy. Your OUTRAGE! is based on ignorance. If there were even a theoretical way to screen for BRCA as effectively as cervical cancer, we would have tried it. Same for Ovarian and lung cancers--also big killers of women. Medicine laments this all the time. I agree with previous poster--you sound like an impetuous child. Would you like science to just make something up for you, Cindy?

the difference between Pap smears and mammograms

By: dora.west | Tue, 11/17/2009 - 16:05

Cervical cancer evolves very slowly in the surface cells of the cervix - they are very easy to sample and examine over the long period time during which they are becoming more and more abnormal. By the time the abnormal cells metastasize (become cancer), they have been detectable in cells that you can easily see and sample with tools no more complicated than a popsicle stick.

Breast cancer metastasizes at a very early stage. There need only be a few abnormal cells in the lining of the milk ducts before they grow through the base membrane and begin to travel around (become cancer). No matter how fancy mammograms become, they will never be able to detect four cells of breast cancer. Not everyone with breast cancer will die of it, because many of them are slow growing and the human body somehow gets rid of some of them by itself. This is why mammograms have had almost no effect on the death rate from breast cancer. Better treatments have been shown to decrease the death rate - it makes much more sense to spend money on better treatments of the cancer that are actually threatening the woman's life rather than scaring to death a whole bunch of women who would have lived happy lives and never known they had cancer at all.

With many medical technologies, it seems we're stuck in the 70s

By: doubleXXX | Tue, 11/17/2009 - 14:48

Is it really true there have been no advances in mammography in terms of a) reducing exposure to radiation, b) getting better pictures, c) making it more comfortable?

"And that’s why I’m outraged."

So actual doctors and not blog writers have spent by your own admission lots of money but haven't given you the golden goose you demand?

I honestly don't know, but instead of your post where all you manage to do is convey your outrage, OUTRAGE, that you can't have an oompa loompa OR a golden goose you may consider committing an act of journalism and asking a few doctors and technicians what has happened with mammography in the past 20 years and what does the future look like?

There are some procedures that I too think must be stuck in the 50s, and I guess they work well enough, maybe there is no research.

But actually I figure I just don't know, so I keep my shit in my ass and don't go all OUTRAGED OUTRAGED on everyone for not giving me a ....

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